Place rotator cuff sutures
Subscapularis and supraspinatus tendon
Begin by inserting sutures into the subscapularis tendon (1) and the supraspinatus tendon (2). Place these sutures just superficial to the tendon’s bony insertions. These provide anchors for reduction, and temporary fixation of the greater and lesser tuberosities.
Next, place a suture into the infraspinatus tendon insertion (3). This can be demanding, and may be easier with traction on the previously placed sutures, or with properly placed retractors.
Variations depending on the approach chosen
Inserting sutures into the infraspinatus tendon is easier with a lateral approach. A) shows a deltopectoral approach and B) an anterolateral (transdeltoid) approach.
Use of stay sutures
Anterior traction on the supraspinatus tendon helps expose the greater tuberosity and infraspinatus tendon.
Insert a preliminary traction suture into the visible part of the posterior rotator cuff …
… and pull it anteriorly. This will expose the proper location for a suture in the infraspinatus tendon insertion. Then the initial traction suture is removed.
Pearl: larger needles
A stout sharp needle facilitates placing a suture through the tendon insertion.
Pearl: use of retractors
Use of blunt, curved Hohmann retractors underneath the deltoid muscle can be helpful to expose the humeral head.
Similarly, a so-called delta retractor may improve deltoid retraction.
Pitfall: use of forceps or clamps in osteoporotic bone
Grabbing bone fragments with a forceps or clamp will typically increase comminution of osteoporotic bone. This should be avoided by using sutures as “handles” for manipulation and reduction.
Reduction of the humeral head
The varus displaced humeral head has to be lifted first. Due to the degree of impaction the force applied to reduce the humeral head might vary.
Use a periosteal elevator in combination with ligamentotaxis to reduce the humeral head.
Additional valgus force could be helpful. This can be achieved by pressing on the proximal humerus from lateral.
Perform the reduction under image intensifier control.
Note: slight medial impaction is desirable
Anatomic reduction of the calcar is not needed in all cases. A slight impaction at the medial side might even increase the stability of the reduction.
Fix the humeral head temporarily
Secure the reduced humeral head temporarily using 2 or 3 K-wires. As shown, they are placed from distal to proximal.
Make sure that they are anterior enough to avoid interfering with the plate application.
If the greater tuberosity is comminuted, additional smaller K-wires may be needed to fix separated fragments.
Reduce the tuberosities
If the humeral head is properly reduced and the correct inclination of the humeral head is achieved, the tuberosities can now easily be positioned underneath the humeral head. Pull the sutures between the subscapularis and the infraspinatus tendons horizontally …
… and tie them together.
After preliminary fixation check the reduction visually and by image intensification.
There should be no gap or step-off between the tuberosities. The inferior spike of the greater tuberosity should fit snugly against the shaft fragment.
The AP x-ray should show the correct relationship between the humeral head and the tuberosities.
Superolaterally, the humeral head and the greater tuberosity should be flush without a step-off or gap.
Confirm the inclination of the humeral head. The centrum collum diaphyseal angle (CCD) is illustrated. It is the angle between the axis of the humeral diaphysis, and the axis of the humeral neck, best identified as a perpendicular to the base of the humeral head. A CCD of less than 120° may predict a secondary collapse.
This intraoperative x-ray shows an unacceptable step-off.
Check the position of the humeral head in the axial/lateral view and be sure that there is no anteversion or excessive retroversion of the humeral head. This view might also reveal malpositioned tuberosities.
In order to maintain fracture reduction in unstable situations (even with preliminary K-wire fixation) move the C-arm and not the patient’s arm when obtaining the axial/lateral.